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0.5 <br /> SAN JOAQUIN LOCAL HEALTH- DISTRICT Dom. <br /> FOF, OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application!- is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work',herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and th les and e ulations o the San Joaquin L al Hera h District. <br /> 1 ,��tj <br /> CENSUS TRACT <br /> JOBIATION <br /> Phone <br /> Owner's Name <br /> City <br /> k Address <br /> i <br /> Contractor's Name m <br /> icense # �5b�b Phone �� <br /> TYPE OF WORK (Check) : `'ANEW WELL/TrDEEPEN / RECONDITION / DESTRUCTION /7 <br /> ;,PUMP INSTALLATION. REPAIR / / PUMP REPLACEMENT 17 <br /> DISTANCE TO NEAREST: `SEPTICr.TANK= SEWER LIES (3 Q PIT PRIVY <br /> SEWAGE DISPOSAL FIELD C�� CESSPOOL/SEEPAGE PIT C �_ OTHER <br /> PROPERTY LINE — PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL �� Q <br /> INTENDED USE TYPE-OF-WELL`a,--- CONSTRUCTION SPECIFICATIONS <br /> r Industrial Cable Tool Dia. of Well Excavation <br /> domestic/private, Drilled *� Dia. of Well Casing d <br /> Domestic/public Driven", . Gauge of Casing <br /> Irrigation : Gravelj L&k Depth of Grout Sea <br /> Cathidic Protection �IFot°ary u Type of Grout _ t��.f-rj J L <br /> Disposal ° Other ,. Other Information <br /> y Geophysical , '`µ Y ' Surface Seal Installed B <br /> i <br /> PUMP INSTALLATION: Contractor <br /> :i Type of Pump H.P. ; <br /> r <br /> PUMP REPLACEMENT: / / State Work Done/! <br /> v, <br /> PUMP .REPAIR: / State Work Done <br /> DESTRUCTION OF WELL: " Well Diameter Approximate Depth <br /> I ' Describe Material and Procedure <br /> I hereby i.greelto comply with'all laws and regulations of the San Joaquin Local Health District <br /> and the State of California -pertaining to•or,5.regulating well'construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well' I will furnish the San Joaquin Local Health District a <br /> 31 <br /> WELL DRIL :ERS REPORT of the well and notify them before putting the .well in use. The above <br /> info a 'on is true tothe o .wledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR G' UTING'AND�A FIN I EC. ION. , <br /> k SIGN TITLE O�--� C� <br /> PIs T" PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE, <br /> APPLICATION ACCEPTED BY DATE _ <br /> ADDITIONAL COMMENTS: <br /> T PHASE III/FINAL INSPECTION <br /> ,-.f PHASE II:i-GROUT INSPECTION -��' <br /> INSPECTION—BY <br /> DATE /D i� 7 INSPECTIONBYv DATE �A _ �',� <br /> 3/76 2M <br /> E H 1426 Rev. 1=74 , <br /> t ,� - <br />